Provider Demographics
NPI:1861651507
Name:SOUTHWEST VIRGINIA EYE CENTER, PLLC
Entity Type:Organization
Organization Name:SOUTHWEST VIRGINIA EYE CENTER, PLLC
Other - Org Name:SOUTHWEST VIRGINIA EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:STANWOOD
Authorized Official - Last Name:TILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-772-3978
Mailing Address - Street 1:3090 ELECTRIC RD
Mailing Address - Street 2:FSUITE B
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3503
Mailing Address - Country:US
Mailing Address - Phone:540-772-3978
Mailing Address - Fax:540-400-0001
Practice Address - Street 1:3090 ELECTRIC RD
Practice Address - Street 2:FSUITE B
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3503
Practice Address - Country:US
Practice Address - Phone:540-772-3978
Practice Address - Fax:540-400-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040106207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty